Hypertension. 1998;31:1136-1145
(Hypertension. 1998;31:1136-1145.)
© 1998 American Heart Association, Inc.
Knowledge, Attitudes, and Practices on Hypertension in a Country in Epidemiological Transition
Line Aubert;
Pascal Bovet;
Jean-Pierre Gervasoni;
Anne Rwebogora;
Bernard Waeber;
; Fred Paccaud
From the Institute of Social and Preventive Medicine, Faculty of Medicine
(L.A., J.-P.G., F.P.), and the Division of Hypertension, University Hospital
(B.W.), University of Lausanne, Switzerland; and the Unit of Prevention and
Control of Cardiovascular Disease, Ministry of Health, Seychelles (P.B.,
A.R.).
Correspondence to Dr Pascal Bovet, Institute of Social and Preventive Medicine, Faculty of Medicine, University of Lausanne, Bugnon 17, 1005 Lausanne, Switzerland. E-mail pascal.bovet{at}inst.hospvd.ch
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Abstract
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Abstract—Assessment of knowledge,
attitudes, and practices (KAP) is a crucial element of hypertension
control, but little information is available from developing countries
where hypertension has lately been recognized as a major health
problem. Therefore, we examined KAP on hypertension in a random sample
of 1067 adults aged 25 to 64 years from the Seychelles Islands (Indian
Ocean). KAP were assessed from an administered structured
questionnaire. The age-standardized prevalence of hypertension
(screening blood pressure [BP] 
160/95 mm Hg or taking
antihypertensive medication) was 36% in men and 25% in women aged 25
to 64 years. Among hypertensive persons, 50% were aware of the
condition, 34% were treated, and 10% had controlled BP (ie, BP
<160/95 mm Hg). Most persons, whether nonhypertensive, unaware
hypertensive, or aware hypertensive, had good basic knowledge related
to hypertension determinants and consequences, possibly an effect of a
nationwide cardiovascular disease prevention program
over the last years. However, favorable outcome expectation, positive
attitudes, and appropriate practices for hypertension and relevant
healthy lifestyles were found in smaller proportions of participants,
with little difference between aware hypertensives, unaware
hypertensives, and nonhypertensives. Furthermore, hypertensive persons
with other concurrent cardiovascular risk factors
affecting the overall heart risk knew well the detrimental effects of
these other factors but reported making little actual change to control
them (particularly regarding overweight and sedentary habits). These
data point to the need to maximize the efficiency of hypertension
prevention and control programs so that delay in achieving effective
hypertension control is minimized in countries experiencing recent
emergence of hypertension as a major public health problem.
Key Words: knowledge, attitudes, practices • developing countries • epidemiology • Africa • Indian Ocean islands
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Introduction
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Hypertension has
become a significant problem in many developing countries experiencing
epidemiological transition from communicable to noncommunicable chronic
diseases.1 2 3 The emergence of hypertension and
other CVDs as a public health problem in these countries is strongly
related to the aging of the populations, urbanization, and
socioeconomic changes favoring sedentary habits, obesity, alcohol
consumption, and salt intake, among others.4 5 A
cost-effective use of health services to control these emerging chronic
diseases is particularly needed in developing countries because
resources are limited and generally must be shared with the concurrent
burden of persistent communicable diseases.
In this context, hypertension presents a major area of intervention
because it is a frequent condition and is amenable to control through
both nonpharmacological lifestyle factors and pharmacological
treatment. Pharmacological treatment for hypertension has been shown to
be effective in decreasing BP and subsequently
cardiovascular events,6 although
BP levels achieved in treated patients may still be considerably higher
than those in truly normotensive persons. Lifestyle measures for
lowering BP include reduced alcohol intake, reduced sodium chloride
intake, increased physical activity, and control of
overweight.7 8 9 10 11 Lifestyle interventions also
have the potential to reduce the need for or the amount of medications
in hypertensives and prevent high BP from developing in
nonhypertensives. Furthermore, lifestyle interventions are instrumental
in controlling other concomitant cardiovascular risk
factors not necessarily related to hypertension, such as smoking,
raised cholesterol level, or diabetes, hence the importance
of a multifactorial approach to effective risk reduction in
hypertensives.12 13 14 15 16
Several models have been proposed to account for health behaviors and
sustained behavioral changes.17 18 19 20 21 22 23 Although they
may differ in content and perspective, models for behavior change
stress the importance of evaluating the perceptions, attitudes,
beliefs, and outcome expectations of individuals as a crucial means to
understand observed behaviors and to guide behavioral change. A proper
assessment and understanding of KAP factors is particularly helpful in
the area of chronic conditions such as hypertension, for which
prevention and control necessitate a lifelong adoption of healthy
lifestyles.
In Seychelles (Indian Ocean), a middle-income country with a fairly
high standard of health care, CVD currently accounts for >30% of all
deaths.24 Adjusted to the Segi's world
population, the prevalence of hypertension (BP 160/95 mm Hg or
taking antihypertensive medication) was 28% in men and 22% in women
aged 25 to 64 years in a first population survey conducted in
1989.25 In 1991, a nationwide program was
launched to reduce cardiovascular risk factor levels in
the population.26 27 The program has been mostly
targeting the general population and relies on extensive health
education through the mass media, inclusion of a heart health education
program in the primary school curriculum, and several regulatory
measures. Interventions also targeted hypertensive individuals
(high-risk strategy) and included, among others, hypertension
screenings in public and work places and the organization of primary
healthcare–based "heart health clubs," whereby hypertensive
patients are offered interactive teaching sessions on
cardiovascular risk factor
management.28
In this study, we examine KAP for hypertension and associated risk
factors in adults with or without known hypertension to help improve
primary and secondary CVD prevention and control programs. Comparison
of KAP between persons aware of being hypertensive versus persons
unaware of being hypertensives (rather than between persons with high
versus low BP, for example) was made on the assumption that aware
hypertensives were likely to have been exposed to more information,
health care, and personal experience related to hypertension than
persons unaware of being hypertensive. This distinction was also chosen
to gather information that would be useful in shaping the usually
different strategies targeting the "population" (mostly prevention)
and the "patients" (mostly treatment).
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Methods
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The Republic of Seychelles consists of 115 islands in the Indian
Ocean, 1800 km east of Kenya. Of the total population, 89% live on the
largest island, Mahé. According to a census carried out in 1994,
the total population was 73 442, with 49% aged <25, 45% aged 25 to
64, and 6% aged 65 years or more. Approximately 85% of inhabitants
are of predominantly black African descent or have some degree of
mixing with this phenotype.29 The opening
of an international airport in 1971 was followed by a rapid increase of
tourism, a fast economic development (the gross domestic product
per capita increased from US$925 in 1976 to US$5850 in 1994), and major
changes in lifestyles.
The study was designed as a cross-sectional study of the general adult
population. Detailed sampling procedures and methods, as well as
information on social and other background data, have been reported
separately.30 The study protocol had been
approved by the Ministry of Health of the Seychelles. A simple age- and
gender-stratified random sample of all residents aged 25 to 64 years
living on the island of Mahé was drawn using computed population
data from a census carried out in 1987; thereafter it was regularly
updated by the administrative authorities.31 One
hundred sixty persons were selected randomly within each of eight
gender- and 10-year strata. Among this initial sample of 1280
individuals, 28 men and 26 women were dead or abroad at the time the
study was carried out and were consequently excluded, leaving 1226
individuals eligible to participate in the study. All eligible persons
were sent a letter to invite them to attend the survey, and
nonrespondents were actively traced by telephone calls to their home,
work, relatives, and district administrations. The survey was conducted
in the premises of the Ministry of Health at Victoria between July and
December 1994. A total of 1067 persons attended the survey,
corresponding to a response rate of 87.0% (82.4% men versus 91.7%
women; P<.001). Among the 159 eligible persons who did not
attend the study, 38 (23.9%) could not be found (letters returned
unopened by the postal services to the study center and unsuccessful
further tracing). Across the gender-age categories considered in the
sampling, the ratios between the number of persons in the base
population and the number of participants in the survey were 60, 38,
20, and 16 for men aged 25 to 34, 35 to 44, 45 to 54, and 55 to 64
years, and 49, 26, 17, and 17 for women of the same age categories,
respectively.
Three BP readings were obtained at 2-minute intervals with the
subject in a sitting position, after a rest of at least 30 minutes in a
quiet environment. BP was measured using a mercury sphygmomanometer
(Boso) with a standard-width or large cuff for persons with middle arm
circumference 34 cm, respectively. Readings were based on Korotkoff
first and fifth phase sounds. Measurements were carried out by five
trained health professionals who had previous experience with BP
measurement in similar surveys. The average of the last two of three
readings was used for the analyses. Participants were
designated as hypertensive if their systolic BP was 160
mm Hg and/or diastolic BP 95 mm Hg and/or they
were currently taking antihypertensive medication. Blood samples were
collected, and serum total cholesterol level was determined
using standard enzymatic methods. Weight and height were measured and
body mass index was calculated as weight in kilograms divided by height
in meters squared. Participants also underwent other investigations
including electrocardiography,
echocardiography, and arterial
ultrasonography.
A face-to-face structured interview was administered in the local
Creole language to all participants by the five Seychellois health
professionals mentioned above, who had previous experience in
conducting interviews in similar health surveys. The interview,
administered in 25 to 35 minutes, included 216 questions covering
sociodemographic, occupational, and educational variables, as well
as KAP on health and CVD. Ethnicity was assessed by a single other
examiner on the basis of phenotypic appearance. "Awareness" of
hypertension was defined as answering "yes" to the question "Did
a doctor ever tell you that you had high BP?" Smokers were defined as
persons reporting current smoking of at least one cigarette per day on
average; "nonsmokers" thus comprised ex-smokers as well. Alcohol
consumption was estimated as milliliters of alcohol (ethanol) consumed
per day, calculated from several questions on reported type and amount
of alcoholic beverages consumed per week, on average. The level of
physical exercise was classified as low, medium, or high based on a
score combining the reported daily walking time and the number of
sessions dedicated to leisure physical exercise per week. A low level
referred to a walking time of 30 minutes or less per day and
participating in leisure physical exercise less than once per week; a
high level referred to leisure physical exercise at least 3 times per
week or walking at least 50 minutes per day; all other persons were
labeled as having an intermediate level of exercise.
Closed-ended questions most often included three to four answering
options (in addition to the option "I do not know," which was a
possible option for all questions). Answering options were organized in
a fixed sequence (eg, "no" always preceding "yes" and
"causes" always preceding "prevents" in the order of appearance
of answering options proposed to the respondents, irrespective of the
content of the questions). To limit bias due to social desirability,
questions on behavior (eg, "Compared with 12 months ago, is your
weight presently lower, about the same, or higher?") were asked
before questions on desire to change ("Would you like to reduce,
keep, or increase your current weight?") and the latter before
questions on intention ("During the last 12 months, did you seriously
try to reduce weight?"). In addition, KAP questions on specific
lifestyles were embedded in a scattered way throughout the 216
questions to limit the induction of specific answers from previously
given answers and to put less emphasis on less acceptable habits (eg,
drinking habits).
Prevalence of hypertension was standardized for age using the Segi's
world population distribution (weights for age groups 25 to 34, 35 to
44, 45 to 54, and 55 to 64 years of 14/45, 12/45, 11/45, and 8/45,
respectively).32 All other adjustments for age,
gender, or ethnic group were performed using the age and gender
distribution of the whole study sample as the standard. Difference in
adjusted prevalence rates across two categories or more than two
categories was tested with Fisher's exact test and
2 test, respectively, using adjusted numbers
of hypertensive persons rounded to the nearest integer. The relation
between hypertension and variables known to relate independently to
hypertension was examined using multivariate logistic
and linear regression models. Difference in age- and gender-adjusted
KAP rates between awareness hypertension categories was tested with
Fisher's exact test using age- and gender-adjusted numbers of persons
with specified KAP rounded to the nearest integer. Categories of
hypertension awareness status included persons aware of being
hypertensive (AH) and persons unaware of being hypertensive (UH). UH
persons were further subdivided in those found to be nonhypertensive
(UHN) or hypertensive (UHH) on the basis of their BP values taken at
the time of the survey. Analyses were computed using the Stata
5.0 statistical software (Stata Corp). All reported probability values
are two-tailed, and values of P
.05 were considered
significant. No adjustment for multiple comparison was made in this
study.
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Results
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The study sample consisted of 504 (47.2%) men and 563 (52.8%)
women. The ethnic distribution was predominantly black descent in 67%
of the participants, mixed in 20%, white in 8%, and Indian or Chinese
in 5%. The mean±SD age of the participants was 44.6±11.4 years
(44.7±11.4 for men and 44.5±11.5 for women). AH participants were
older than UH participants (50.3±10.2 versus 43.0±11.3 years;
P<.001). Age- and sex-adjusted mean±SD systolic BP
(mm Hg) was 153.0±25.2 in AH, 156.8±18.8 in UH, and 122.3±14.1 in
UHN, while diastolic values were 98.0±14.3, 103.8±8.5,
and 79.7±8.2, respectively.
Prevalence of Hypertension
The age-standardized prevalence of hypertension (BP 160/95
mm Hg or taking medication) was 35.8% in men and 25.0% in women aged
25 to 64 years (43.9% in men and 32.8% in women aged 35 to 64 years).
Age- and sex-adjusted rates of hypertension were higher in men, older
persons, blacks, obese persons, and persons with high serum
cholesterol levels (Table 1
).
Regarding categories of socioeconomic status, the age-, sex-, and
ethnic group–adjusted rates of hypertension were higher in persons
without paid work and in those owning a car (Table 2). Hypertension rate was marginally
higher in persons without versus with secondary education (33.1%
versus 26.3%; P=.068). No consistent trend was
found across job categories.
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Table 1. Age- and Gender-Adjusted Prevalence of Hypertension1
Across Categories of Several Variables and Multiple Logistic
Regression Analysis of Selected Variables on Hypertension
Status
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Table 2. Age-, Gender-, and Ethnic Group–Adjusted Prevalence
of Hypertension1
Across Categories of Selected Socioeconomic
Variables
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Hypertension Correlates
Multivariate logistic analysis indicated
that hypertension in this population was independently associated with
gender, age, black ethnicity, and weight (Table 1
). Odds ratios (95%
confidence interval) for relation to hypertension of moderate and high
level of physical activity were 0.62 (0.45 to 0.86) and 0.83 (0.56 to
1.24), respectively, suggesting a reduced risk of being hypertensive.
Although not statistically significant, odds ratios for moderate and
heavy alcohol consumption were 1.42 (0.94 to 2.13) and 1.46 (0.88 to
2.43), respectively, which may indicate greater risk of being
hypertensive. None of these factors significantly interacted with
gender in this model. The area under the receiver operating
characteristic curve for the logistic multivariate
model shown in Table 1 was 0.76. Multivariate linear
models including the same categorical variables showed an explained
variance of 24.2% for estimation of systolic BP and 20.9% for
estimation of diastolic BP. Alcohol intake independently
related to both systolic and diastolic BP values in
these linear regression models (data not shown).
Awareness and Control of Hypertension
Table 3 shows the proportion of
hypertensive persons who were aware, treated, and controlled in the
population, by gender and age. All values were higher in women than in
men of same age and in older than younger persons of same gender.
KAP on Health
Table 4 shows age-adjusted rates of
KAP among hypertension awareness categories. Altogether, 11% of
participants considered that their health was bad; 10% that they were
less healthy than persons of the same age; 6% that they could get a
heart attack or a stroke in the next few years; 23% thought that they
could do much to prevent a heart attack or stroke; 20% thought that
they should do more for their own health; and 17% thought that one's
lifestyle habits can greatly influence future health. Compared with UH
participants, AH participants perceived themselves as less healthy and
more likely to get myocardial infarction or stroke. Although not
statistically significant, lower proportions of AH than UH subjects
believed that one can do much to prevent CVD or that lifestyle habits
greatly influence future health. Among UH participants, perception of
health was generally similar in persons with nonhypertensive BP values
(UHN) or high BP values (UHH).
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Table 4. Age- and Gender-Standardized Prevalence of KAP on
Health and Hypertension by Hypertension Awareness Categories
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KAP on Hypertension
A high proportion of participants (both AH and UH) showed good
basic knowledge on hypertension. For example, >96% knew that salt and
obesity were associated with hypertension and that hypertension was
associated with CVD occurrence. The benefit of physical exercise on BP
was also well recognized, although less frequently (79% of
participants). Most persons reported that smoking causes high BP. In
contrast to basic knowledge, specific knowledge on hypertension was
less. For example, 28% of all participants knew that hypertension only
rarely causes symptoms (whereas around a quarter thought that
hypertension almost always causes symptoms), 10% could give values for
their own BP, and 14% could give a value for "normal" BP.
Compared with AH, UH participants showed similar basic knowledge.
In contrast, specific knowledge was significantly better in AH than in
UH subjects. For example, 27% of AH versus 7% of UH knew a value for
their own BP, 21% AH versus 12% UH could give a value for
"normal" BP, and 56% AH versus 45% UH knew that antihypertensive
medication must generally be taken for years. However, AH did not know
better than UH that hypertension rarely results in symptoms (25%
versus 29%; NS), and AH thought more often than UH that hypertension
almost always causes symptoms (36% versus 24%; P<.001).
Regarding reported practices, AH visited a doctor more often than UH
(mean±SD, 5.5±4.6 versus 2.8±3.7 visits per year;
P<.001), and AH had more often had their BP checked within
the previous month than UH (40% versus 17%; P<.001). AH
reported marginally more often than UH making an effort to eat small
amounts of salt (70% versus 63%; P=.076). Among UH,
knowledge was generally similar in UHN and UHH (Table 4). However,
compared with UHN, UHH visited a doctor less often (66% versus 75%;
P=.028), and fewer had had BP checked recently (11% versus
18%; P=.020).
Basic knowledge tended to be better in women than in men (data
not shown). Women also tended to have better specific knowledge,
although these values were low for both genders. For example, 13% of
women versus 8% of men (P=.012) could give a value for
their own BP, and 17% versus 11% (P=.014) could give a
value for "normal" BP values.
KAP on Other Concomitant Cardiovascular Risk
Factors
Table 5 shows age-adjusted
rates of KAP on other concomitant cardiovascular risk
factors amenable to control among hypertension awareness categories.
Because <1% of women (5 individuals) reported heavy drinking,
analyses on alcohol consumption were restricted to men.
Knowledge about detrimental lifestyle habits (as assessed by the
question "Do you think that ... is detrimental to health") was
high, with more than 70% of smokers, heavy drinkers, persons with
little physical activity, and overweight persons (both AH and UH)
recognizing the detrimental effect of these conditions to their own
health. Regarding attitudes, similarly high proportions of persons
(between 73% and 95%) with one or more of these four concomitant risk
factors expressed the wish to reduce the corresponding detrimental
condition (as assessed by the question "Would you like to
reduce... "). Attempt to change (as assessed by the question
"During the last 12 months, have you seriously tried to reduce ...
") was reported by smaller proportions of participants: 74% of
smokers, 60% of heavy drinkers, 56% of overweight persons, and 16%
of persons with low physical activity. Actual behavior change in the
considered-unhealthy lifestyles over the last 12 months (as assessed by
the question "Compared with 12 months before, have you
increased/reduced... ") was reported less frequently: 65% of
smokers, 54% of drinkers, 25% of overweight persons, and 6% persons
with little physical activity.
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Table 5. Age- and Gender-Standardized Prevalence of KAP on
Selected Cardiovascular Risk Factors by
Hypertension Awareness Categories
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These KAP findings on concomitant risk factors did not differ
substantially between AH and UH participants, with a few exceptions.
For example, more AH than UH heavy drinkers (96.3% versus 71.3%;
P=.020) thought that their alcohol consumption was harmful
to their health; and more AH than UH with low physical activity (79.9%
versus 65.6%; P=.005) considered themselves as getting too
little exercise. In contrast, fewer AH than UH smokers expressed the
wish to reduce smoking (84.9% versus 95.2%; P=.027); and
fewer AH than UH overweight persons knew that overweight causes
hypertension (88.0% versus 97.0%; P=.001) or thought that
lifestyle can influence future health (12.2% versus 21.4%;
P=.029). Among subcategories of UH, there was little
difference between UHN and UHH. However, UHN smokers thought more often
than UHH smokers that lifestyle greatly influences future health
(20.2% versus 6.6%; P=.015), and they more often expressed
the wish to reduce smoking (95.2% versus 84.1%;
P=.032).
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Discussion
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Hypertension Prevalence
The prevalence of hypertension (screening BP 160/95 mm Hg
or taking medication) was 43.9% and 32.8% in men and women aged 35 to
64 years, after age adjustment to the world population. Based on the
same age standardization and BP detection methods, these values are
higher than those in several industrialized countries participating in
the WHO MONICA project (eg, Switzerland, 18.1% and 14.0%;
Scotland, 32.0% and 25.4%; but not Finland, 45.3% and
37.6%)33 or in the American NHANES II study
(white population, 28.0% and 24.6%; but in the black population,
39.0% and 47.3%).34 Hypertension prevalence is
also higher in Seychelles than in many developing
countries2 (eg, Tanzania, 13.7% and
14.535 ; or China, 24.6% and
21.5%33), although high hypertension rates have
been reported in selected urban settings (eg, 23% and 27% in a Zulu
urban setting of South Africa36 or 35% and 23%
in Sao Paulo).37 The high prevalence of
hypertension in Seychelles is consistent with a particularly
high incidence of stroke recorded in the
country.38 39
In our cross-sectional data, high BP was associated independently with
male gender, older age, black ethnic group, and high body mass index.
High BP tended to be also associated with high alcohol intake and low
physical activity. These findings are not unexpected, since these
factors have consistently been shown to relate causally to
hypertension in other populations.12 In
Seychelles, no clear association was found with socioeconomic status.
An inverse association between socioeconomic status and hypertension
has been found in several developed and developing
countries,12 40 while a direct relationship was
found in developing countries at an earlier stage of the
epidemiological transition.41
Awareness and Control of Hypertension
An intermediate proportion (50%) of individuals with high BP was
aware of being hypertensive, and only a small proportion (10%) of
hypertensive persons had controlled BP. With the use of similar
population-based sampling and case definition, these figures are lower,
for example, than in African Americans in 1991 to 1993 (93% aware,
83% treated, and 68% with BP controlled)42 or
in Barbados in 1994 (82% aware, 60% treated, and 52%
controlled).43 Rates of hypertension control in
Seychelles were, however, higher than those in several developing
countries, eg, in rural Zaire in 1986 (31% aware, 13% treated, and
3% controlled)44 or in the Eastern Mediterranean
region in 1990 (only about 20% of hypertensives aware of their
condition),45 where hypertension has been
recognized as a major local public health problem only recently.
Intermediate rates of hypertension awareness and control in Seychelles
are not unexpected findings because hypertension has become a major
health concern only lately, possibly a consequence of the rapid
epidemiological transition over the last two or three decades. Although
a nationwide program of prevention and control of CVD was initiated in
1991, substantial achievement of these goals may require more time. Low
rates of BP control in the population are consistent with a
poor adherence to treatment, as assessed by electronic monitoring: only
28% of newly diagnosed hypertensive persons achieved 360-day adherence
of at least 85% on one-pill-per-day
medication.46 Overall, it might be considered
that the current detection and control rates in Seychelles compare with
what prevailed in western countries for several decades and was
referred to, in the 1970s, as "the rule of the halves" (where half
of hypertensives are aware of hypertension, half of aware hypertensives
are treated, and half of those treated are
controlled).47 It took no fewer than 30 to 40
years of sustained effort to substantially improve hypertension
detection and control in western countries, and rates are still far
from optimal.48 Rapidly improving hypertension
detection and control, more quickly than was achieved in western
countries, is therefore much needed to prevent or reduce the
increasingly large burden of disease related to increasing rates of
hypertension in countries in epidemiological transition.
Limitations in Measuring KAP
KAP assessment from population surveys invariably poses the
problem of social desirability, whereby respondents are reluctant to
admit socially poorly acceptable KAP to avoid giving a negative
impression.49 50 The fact that about 90% of
respondents answered that smoking causes high BP (while smoking is
generally not recognized as a strong risk factor for hypertension) may
reflect such a social desirability effect; alternatively, this finding
may relate to a diffusion effect of the ongoing CVD prevention program
whereby several "unhealthy" behaviors are associated with
detrimental cardiovascular outcomes. Attempts to limit
socially desirable or induced answers were implemented in the study
questionnaire. KAP questions pertaining to specific sensitive topics
(eg, alcohol habits, overweight) were embedded among questions relating
to other issues to make questions appear as ordinary as possible, hence
expectedly improving self-reporting of actual KAP in such instances.
Embedding questions on alcoholic consumption within the context of
general diet questionnaires has indeed been found to enhance
self-reporting of alcohol intake.51 Answer
options provided to the respondents (eg, "no, yes, do not know";
"causes, prevents, no effect, do not know") were
consistently asked in the same sequence, and the questions
consistently included the option to either accept or reject the
question premises so that the "right" answers could not be
anticipated. Notwithstanding these efforts, self-reported KAP remain
likely to be biased toward socially expected norms, which currently
tend to correspond to healthy ones.
KAP in Unaware Hypertensives
By showing low rates of health-appropriate KAP on hypertension in
UH, this study indicates the presence of barriers to the adoption of
healthy lifestyle habits by the general population, a problem
repeatedly identified in KAP studies in western
countries.52 53 54 Although basic knowledge on
cardiovascular health was high—consistent with
the ongoing CVD prevention program relying largely on diffusion of
health messages through the mass media—specific knowledge was low, and
attempts to adopt healthy lifestyles were infrequent. Importantly, the
study suggests that most persons did not perceive CVD as a serious
threat (only 6% of all participants thought they could get a heart
attack or a stroke within the next few years), and most persons had low
outcome expectation as regards adoption of healthy lifestyles (only
17% thought that lifestyle habits can greatly influence future
health).
KAP in Aware Hypertensives
AH participants showed better specific knowledge on hypertension
than UH (both UH and UHN). AH knew more often, for example, their own
BP values or normal BP values and reported making a greater effort to
eat small amounts of salt. This is consistent with the fact
that compared with UH, AH visit a doctor more often and may be more
receptive to hypertension-related education from medical or mass media
sources. However, compared with UH, AH showed similarly low confidence
that lifestyle can influence health. Furthermore, attitudes and
practices on concomitant risk factors were globally not better in AH
than in UH, which indicates a limited understanding of compounding of
cardiovascular risk by concomitant risk factors and
potential benefit of nonpharmacological measures as important adjuncts
for hypertension control.50 54 55
Resistance to adopting healthy lifestyles may indicate, in keeping with
Bandura's social learning theory,20 a situation
in which environmental cues do exist (good basic knowledge) but fall
short because of the relatively low outcome expectation (low confidence
that a behavior may actually influence health). In terms of Farquhar's
model of behavioral change,21 our findings
suggest that most persons have acquired sufficient knowledge but only a
few show real motivation (wish and attempt) to change, and very few
have reached the stages of skills and action whereby individuals
actively engage in a new behavior. Various explanations underlie low
outcome expectation on chronic disease control and resistance to
actually adopting healthy lifestyles. First, lay persons may
underestimate the serious consequences of hypertension because of its
silent evolution, chronic nature, and delayed impact on health
outcomes. Second, lifestyle patterns prevailing in a society at a
certain time are shaped by common attitudes, beliefs, behaviors, and
social conditions and tend to be stable over time. Third, individual
indulgence in immediately "pleasurable" behaviors (eg, enjoying
fatty and salty food, avoiding physical exercise, smoking) is a
powerful deterrent for adopting behaviors such as regular physical
exercise, moderation in salt, alcohol and caloric intake, or abstinence
from smoking.56 Finally, individuals may perceive
that they lack the skills to adopt healthy lifestyles or that they
cannot afford them. This latter mechanism may account for our finding
that AH, particularly the obese ones, expressed less confidence than
their nonhypertensive counterparts that lifestyle habits can influence
health.
Public Health Implications
KAP findings in this study have several public health implications
for the general population and the hypertensive patients. While the
currently good basic knowledge on hypertension in the general
population may have resulted from ongoing health education through the
mass media, the limited detailed knowledge indicates the need to
develop more specific health education programs. In addition, limited
motivation to adopt healthy lifestyles stresses the need to further
develop an environment conducive to such healthy lifestyles.
Importantly, adoption of healthy lifestyles by larger segments of the
population is likely to depend on further development of relevant
public policies, including development of more facilities and
opportunities for the public to engage in leisure physical exercise,
improved food labeling and other incentives to promote a healthy diet,
regulatory measures to promote a smoke-free society, and the policy for
adults to have annual BP checks. Regarding a high-risk strategy,
hypertensive patients need to be equipped with more skills to be able
to make healthy choices and adhere to long-term pharmacological
regimens. This implies that doctors and other health professionals must
be acquainted with relevant guidelines for hypertension management and
relevant behavior change techniques.21 23 57
Conclusion
Because hypertension is emerging as a major public health problem
in many developing countries undergoing epidemiological transition, it
is essential to gather both epidemiological and KAP data on
hypertension as crucial steps in the design of sound prevention and
control programs. It is particularly important to maximize the
efficiency of such programs in these countries to minimize delay in
achieving effective hypertension control.
|
Selected Abbreviations and Acronyms
|
|---|
| AH |
= |
persons aware of being hypertensive |
| BP |
= |
blood pressure |
| CVD |
= |
cardiovascular disease |
| KAP |
= |
knowledge, attitudes, and practices |
| UH |
= |
persons unaware of being hypertensive |
| UHH |
= |
persons unaware of being hypertensive and who are hypertensive |
| UHN |
= |
persons unaware of being hypertensive and who are nonhypertensive |
|
|
Acknowledgments
|
|---|
The authors thank Guy van Melle, PhD (Institute of Social and
Preventive Medicine, Unit of Biostatistics, University of Lausanne),
for his valuable assistance in conducting statistical analyses;
the Ministry of Health of Seychelles for its support to health
research; and all participants in the study. Dr Bovet is the recipient
of a grant from the Swiss National Foundation for Science (No.
3233-038792.93).
Received July 7, 1997;
first decision August 4, 1997;
accepted December 2, 1997.
|
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Top
Abstract
Introduction